Results of surgical treatment in patients, suffering diabetes mellitus and chronic critical ischemia of lower extremity, taking into account the data of intraoperative debitometry

Keywords: intraoperative debitometry; the shunt debit; diabetes mellitus; chronic critical ischemia of lower extremity; the hybrid arterial reconstruction; ischemic form of a diabetic foot syndrome.

Abstract

Objective. To analyze the results of surgical treatment of patients, suffering diabetes mellitus, ischemic form of diabetic foot syndrome and chronic critical ischemia of the lower extremity, caused by stenotic-occlusive affection of femoral arterial and popliteo-tibial segments, taking into account the data of intraoperative debitometry.

Materials and metods. Results of surgical treatment were analyzed in 67 patients, suffering diabetes mellitus Type II, ischemic form of diabetic foot syndrome and chronic critical ischemia of the lower extremity, caused by stenotic-occlusive affection of femoral arterial and popliteo-tibial segments in 1 and 12 mo. In all the patients a femoro-popliteal shunting without intervention on the popliteo-tibial segment was performed. In accordance to the results obtained during intraoperative debitometry, the patients were distributed into three Groups: Group I - 22 patients with the shunt debit more than 60 ml/min, Group II - 25 patients with the shunt debit 30-60 ml/min, and Group III - 20 patients with the shunt debit lesser than 30 ml/min. In thrombosis of primary zone of arterial reconstruction a reoperation was conducted - a hybrid arterial reconstruction of the popliteo-tibial (thrombectomy from shunt and the balloon angioplasty) segment arteries.

Results. In a Group I (n=22) a primary passability of the arterial reconstruction zone in 1mo was observed in 20 (90.9%), and in 12 mo - in 17 (77.3%) patients; in Group II (n=25) - accordingly, in 19 (76%) and 14 (56%) patients; in Group III (n=20) - accordingly, in 9 (45%) and 4 (20%).

Thronbosis in the arterial reconstruction zone was diagnosed during a year in 32 patients, of them during first month after primary shunting - in 19 (59.4%), during further 11 mo - in 13 (40.6%) patients. After reoperation for thrombosis of the arterial reconstruction zone, consisting of a hybrid arterial reconstruction, secondary passability of the arterial reconstruction zone during 12 mo was observed in 24 (75%) of 32 patients. While restoration of outflow from popliteal artery into one tibial artery (n=23) during 12 mo a rethrombosis of the arterial reconstructive zone have occurred in 7 patients, secondary passability of the arterial reconstruction zone during 12 mo was observed in 16 (69.6%) patients. While restoration of outflow from popliteal artery into two tibial arteries (n=9) during 12 mo rethrombosis of the arterial reconstruction zone have occurred in 1 patient, secondary passability of the arterial reconstruction zone during 12 mo was observed in 8 (88.9%) patients.

Conclusion. In combined stenotic-occlusive affection of femoral arterial segment and arteries of popliteo-tibial segment the isolated restoration of passability and femoral arterial segment without intervention on arteries of popliteo-tibial segment necessitates taking into account the intraoperative debitometry data with determination of the shunt debit constitutes an effective diagnostic method, the data of which may help to adjust a differentiated approach to tactics of surgical treatment in patients, suffering diabetes mellitus, chronic critical ischemia of the lower extremity, caused by stenotic-occlusive affection of femoral arterial segment and arteries of popliteo-tibial segment.

The shunt debit bordering value, in presence of which the isolated restoration of the femoral arterial segment passability is possible, constitutes the indices higher than 60 ml/min, further intervention on the popliteo-tibial segment arteries is indicated only in the patients with the shunt thrombosis; while in the shunt debit 30-60 ml/min a reconstruction stage of the popliteo-tibial segment arteries after restoration of the femoral arterial segment passability may be postponed and performed on second stage of the procedure; while the shunt debit lesser than 30 ml/min - a simultaneous reconstruction of femoral segment and of the popliteo-tibial arteries, using performance of a hybrid arterial reconstruction, is necessary. The last is effective method of restoration of blood circulation in patients, suffering diabetes mellitus and chronic critical ischemia of the lower extremity, caused by stenotic-occlusive affection of femoral arterial segment and arteries of popliteo-tibial segment, and in accordance to the results adduced (index of the arterial reconstruction zone passability during 12 mo have constituted 75%) do not differ trustworthily from result of reconstruction of arterial segment in patients of Group I: the shunt debit more than 60 ml/min, while index of the arterial reconstruction zone passability during 12 mo constitutes 77.3% (p>0.05).

While thrombosis of primary zone of arterial reconstruction the addition of thrombectomy from the shunt by restoration of the main blood flow from popliteal into two tibial arteries, using the balloon angioplasty, demonstrates a trustworthy best index of secondary passability of the arterial reconstruction zone in 12 mo - 88.9%, comparing with index of secondary passability of the arterial reconstruction zone in 12 mo after restoration of the main blood flow from popliteal artery into one tibial artery - 69.6% (p< 0.05).

Author Biographies

S. M. Didenko, Clinical Hospital «Feofania», Kyiv

Didenko S.N., MD, DSci(Med), vascularsurgeon,
Center of vascular surgery,
Clinical Hospital «Feofaniya».
21, Zabolotnogo Str., 03143, Kyiv, Ukraina,
+38 (044) 259-65-74, +38 (095) 643-43-34.
ORCID: http://orcid.org/0000-0002-3115-7524

Yu. M. Hupalo, Scientific-Practical Center of Prophylactic and Clinical Medicine, Kyiv

Hupalo Y.M., MD,PhD,
leading researcher at the department of minimally invasive surgery,
Research and Practical Center of Preventive and Clinical Medicine.
5,Verchniay Str., 01014, Kyiv, Ukraina,
+380679367820
uriy_gupalo@ukr.net
http://orcid.org/0000-0002-4856-1398

V. Yu. Subbotin, Clinical Hospital «Feofania», Kyiv

Subbotin V.Y., MD, vascular surgeon,
head of the Center of Vascular Surgery,
Clinical Hospital «Feofaniya».
21,Zabolotnogo Str., 03143, Kyiv, Ukraina,
+38 (044) 259-67-70
vitaliksub@ukr.net
http://orcid.org/0000-0002-1538-7004

A. M. Kutsyn, Clinical Hospital «Feofania», Kyiv

Kutsyn A.N., vascular surgeon,
Center of vascular surgery,
Clinical Hospital «Feofaniya».
21Zabolotnogo Str., 03143, Kyiv, Ukraina,
+38 (044) 259-65-19, +38 (063) 590-81-56
kutsyn.anton@gmail.com
http://orcid.org/0000-0001-9421-8032

A. A. Jaghdal, Institute of Posgraduate Education of Bogomolets National Medical University, Kyiv

Jaghdal, surgeon-intern,
teaching assistant
Department of Surgery, AnesthesiologyandIntensiveCareofPostgraduateStudy,
Institute of postgraduate study of BogomoletsNationalMedicalUniversity
Ukraine, Kyiv,Peremohy Avenue 36, 02000
+38(099) 601-84-32
annushka772@gmail.com
http://orcid.org/0000-0002-3477-1837

References

Shah B, Rockman CB, Guo Y. Diabetes and vascular disease in different arterial territories. Diabet Care. 2014;37(6):1636-42.doi: 10.2337/dc13-2432.

Takayama T, Matsumura JS. Complete Lower Extremity Revascularization via a Hybrid Procedure for Patients with Critical Limb Ischemia. Vasc Endovascular Surg. 2018 May;52(4):255-61. doi: 10.1177/1538574418761723.

Thiruvoipati T, Kielhorn CE, Armstrong EJ. Peripheral artery disease in patients with diabetes: Epidemiology, mechanisms, andoutcomes. World J Diabetes. 2015;6(7):961-9. doi: 10.4239/wjd.v6.i7.961.

Das SK, YuanYF, Li MQ. Predictors of delayed wound healing after successful isolated below-the-knee endovascular intervention in patients with ischemic foot ulcers. J Vasc Surg. 2018;67(4):1181-90. doi: 10.1016/j.jvs.2017.08.077.

Boyko VV, Ivanova JuV, Krivoruchko IA, Didenko SN, Mushenko EV. Korobov AM. Lechenie ishemicheskoj formy sindroma diabeticheskoj stopy. Klin Khir. 2018;85(2):18-21. doi: 10.26779/2522-1396.2018.02.18. [In Russian].

Volodos NL, Kalashnikova YuV, Trojan VI, Krivchikov YuN. Determination of the throughput of the distal vascular bed and graft in arterial operations. Grekov's Bulletin of Surgery.1988;140(3):64-7. [In Russian]

Rutherford RB, Baker JD, Ernst C, Johnston KW, Porter JM. Recommended standards for reports dealing with lower extremity ischemia: revised version. J Vasc Surg.1997;26(3):517-38. doi: 10.1016/s0741-5214(97)70045-4. Erratum in: J Vasc Surg 2001 Apr;33(4):805. PMID: 9308598.

Didenko SM, Lysaichuk YuS, Hupalo YuM, Shved OE, Subbotin VYu, Kutsyn AM, vynakhidnyky; Didenko SM, Lysaichuk YuS, Hupalo YuM, Shved OE, Subbotin VYu, Kutsyn AM, patentovlasnyk. Sposib vyznachennia yemnosti arterialnoho rusla pidkolinno-homilkovo-stopovoho sehmenta. Patent Ukrainy № 53721. 2010 List10. [In Ukrainian].

Published
2020-07-24
How to Cite
Didenko, S. M., Hupalo, Y. M., Subbotin, V. Y., Kutsyn, A. M., & Jaghdal, A. A. (2020). Results of surgical treatment in patients, suffering diabetes mellitus and chronic critical ischemia of lower extremity, taking into account the data of intraoperative debitometry. Klinicheskaia Khirurgiia, 87(5-6), 36-40. https://doi.org/10.26779/2522-1396.2020.5-6.36
Section
General Problems of Surgery